How does exercise treatment compare with antihypertensive medications? A network meta-analysis of 391 randomised controlled trials assessing exercise and medication effects on systolic blood pressure
Open accessAbstract
Objective: To compare the effect of exercise regimens and medications on systolic blood pressure (SBP). Data sources: Medline (via PubMed) and the Cochrane Library. Eligibility criteria: Randomised controlled trials (RCTs) of angiotensin-converting enzyme inhibitors (ACE-I), angiotensin-2 receptor blockers (ARBs), β-blockers, calcium channel blockers (CCBs) and diuretics were identified from existing Cochrane reviews. A previously published meta-analysis of exercise interventions was updated to identify recent RCTs that tested the SBP-lowering effects of endurance, dynamic resistance, isometric resistance, and combined endurance and resistance exercise interventions (up to September 2018). Design: Random-effects network meta-analysis. Outcome: Difference in mean change from baseline SBP between comparator treatments (change from baseline in one group minus that in the other group) and its 95% credible interval (95% CrI), measured in mmHg. Results: We included a total of 391 RCTs, 197 of which evaluated exercise interventions (10 461 participants) and 194 evaluated antihypertensive medications (29 281 participants). No RCTs compared directly exercise against medications. While all medication trials included hypertensive populations, only 56 exercise trials included hypertensive participants (≥140 mmHg), corresponding to 3508 individuals. In a 10% random sample, risk of bias was higher in exercise RCTs, primarily due to lack of blinding and incomplete outcome data. In analyses that combined all populations, antihypertensive medications achieved higher reductions in baseline SBP compared with exercise interventions (mean difference −3.96 mmHg, 95% CrI −5.02 to −2.91). Compared with control, all types of exercise (including combination of endurance and resistance) and all classes of antihypertensive medications were effective in lowering baseline SBP. Among hypertensive populations, there were no detectable differences in the SBP-lowering effects of ACE-I, ARB, β-blocker and diuretic medications when compared with endurance or dynamic resistance exercise. There was no detectable inconsistency between direct and indirect comparisons. Although there was evidence of small-study effects, this affected both medication and exercise trials. Conclusions: The effect of exercise interventions on SBP remains under-studied, especially among hypertensive populations. Our findings confirm modest but consistent reductions in SBP in many studied exercise interventions across all populations but individuals receiving medications generally achieved greater reductions than those following structured exercise regimens. Assuming equally reliable estimates, the SBP-lowering effect of exercise among hypertensive populations appears similar to that of commonly used antihypertensive medications. Generalisability of these findings to real-world clinical settings should be further evaluated.
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In the general population, exercise can reduce the risk of cardio-metabolic diseases such as obesity, diabetes and metabolic syndrome.
“Specifically, there is a plethora of evidence from the general population that exercise can reduce the risk of cardio-metabolic diseases (such as obesity, diabetes and metabolic syndrome [92,93]).”
From Exercise as Medicine for Mental and Substance Use Disorders: A Meta-review of the Benefits for Neuropsychiatric and Cognitive Outcomes (2020) · cites this paper as [93]
The Introduction (page unavailable) reports lower cardiovascular-disease risk with higher physical activity and says exercise improves waist circumference, HbA1c and other cardiometabolic risk factors. It does not report that exercise reduces the risk of developing obesity, diabetes or metabolic syndrome specifically. (LLM, conf=0.84)
Experimental — accuracy not yet measuredExercise training can provide reductions in BP that are equivalent to pharmacological intervention.
“It is also pertinent that exercise training can provide reductions in BP that are equivalent to pharmacological intervention [63], with the BP-lowering effects of exercise training enhanced when combined with pharmacotherapy [64].”
From The Identification and Management of High Blood Pressure Using Exercise Blood Pressure: Current Evidence and Practical Guidance (2022) · cites this paper as [63]
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Noetel, M., Sanders, T., Gallardo-Gómez, D., Taylor, P., del Pozo Cruz, B., van den Hoek, D., Smith, J. J., Mahoney, J., Spathis, J., Moresi, M., et al. (2024) · BMJ · doi:10.1136/bmj-2023-075847 · Cited by 707 · see citing works
Ashdown-Franks, G., Firth, J., Carney, R., Carvalho, A. F., Hallgren, M., Koyanagi, A., Rosenbaum, S., Schuch, F. B., Smith, L., Solmi, M., et al. (2020) · Sports Medicine · doi:10.1007/s40279-019-01187-6 · Cited by 446 · see citing works
Currier, B. S., Mcleod, J. C., Banfield, L., Beyene, J., Welton, N. J., D'Souza, A. C., Keogh, J. A. J., Lin, L., Coletta, G., Yang, A., et al. (2023) · British Journal of Sports Medicine · doi:10.1136/bjsports-2023-106807 · Cited by 179 · see citing works
Pescatello, L. S., Wu, Y., Gao, S., Livingston, J., Sheppard, B. B., & Chen, M.-H. (2021) · BMJ Open Sport & Exercise Medicine · doi:10.1136/bmjsem-2020-000895 · Cited by 50 · see citing works
Application of network meta-analysis in the field of physical activity and health promotion
Su, X., McDonough, D. J., Chu, H., Quan, M., & Gao, Z. (2020) · Journal of Sport and Health Science · doi:10.1016/j.jshs.2020.07.011 · Cited by 38 · see citing works
Schultz, M. G., Currie, K. D., Hedman, K., Climie, R. E., Maiorana, A., Coombes, J. S., & Sharman, J. E. (2022) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph19052819 · Cited by 27 · see citing works
Martínez-Vizcaíno, V., Amaro-Gahete, F. J., Fernández-Rodríguez, R., Garrido-Miguel, M., Cavero-Redondo, I., & Pozuelo-Carrascosa, D. P. (2022) · Sports Medicine · doi:10.1007/s40279-021-01607-6 · Cited by 24 · see citing works
- Authors
- Naci, H., Salcher-Konrad, M., Dias, S., Blum, M. R., Sahoo, S. A., Nunan, D., & Ioannidis, J. P. A.
- Affiliations
- London School of Economics and Political Science (GB)
- Department of Health Policy, London School of Economics and Political Science, London, UK
- University of Bristol (GB)
- University of Bern (CH)
- University of Pennsylvania (US)
- University of Oxford (GB)
- Stanford Medicine (US)
- Corresponding author
- Naci, Huseyin
- Venue
- British Journal of Sports Medicine
- Publisher
- BMJ
- Published
- 2018-12-18
- Volume
- 53
- Issue
- 14
- Pages
- 859-869
- ISSN
- 0306-3674 (ISSN-L)
- 1473-0480
- OpenAlex
- W2905522163
- Semantic Scholar
- bef06923903d491d81082b4454731785b0055f89
- Cited by
- 326
- References
- 91
- Citations by year
- 2026: 33 · 2025: 33 · 2024: 40 · 2023: 48 · 2022: 46 · 2021: 46 · 2020: 50 · 2019: 22 · 2018: 4
- FWCI
- 5.68
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- British Journal of Sports Medicine (publishedVersion)
- PubMed (publishedVersion)
- Bristol Research (University of Bristol) (publishedVersion, other-oa)
- White Rose Research Online (University of Leeds, The University of Sheffield, University of York) (submittedVersion)
- London School of Economics and Political Science Theses Online (London School of Economics and Political Science) (submittedVersion)
- Bern Open Repository and Information System (University of Bern) (submittedVersion)
- HighWire Press Open Archive (submittedVersion)
- Funders
- National Science Foundation
- Schweizerischer Nationalfonds zur Förderung der Wissenschaftlichen Forschung (175289, P2BEP3)
- Medical Research Council (MR/M005232/1)
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Blood Pressure and Hypertension Studies
- Health Sciences › Medicine › Complementary and alternative medicine › Cardiovascular and exercise physiology
- Health Sciences › Medicine › Physiology › Physical Activity and Health
- Keywords
- exercise therapy, antihypertensive drugs, systolic blood pressure, hypertension, endurance exercise, resistance training, ACE inhibitors, beta-blockers, calcium channel blockers, diuretics, blood pressure reduction, risk of bias, small-study effects
- MeSH terms
- Angiotensin-Converting Enzyme Inhibitors, Antihypertensive Agents, Blood Pressure, Calcium Channel Blockers, Diuretics, Humans, Hypertension, Exercise, Angiotensin Receptor Antagonists
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
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